Name:
A 42-Year-Old with Fever and Hypotension
Description:
A 42-Year-Old with Fever and Hypotension
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Duration:
T00H05M21S
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Upload Date:
2022-02-28T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
♪ (music) ♪
CATHY: Hi, welcome to Harrison's Podclass where we discuss important concepts in internal medicine. I'm Cathy Handy.
CHARLIE: And I'm Charlie Wiener,
CHARLIE: and we're coming to you from the Johns Hopkins School of Medicine. ♪ (music) ♪
CHARLIE: Welcome to Episode 39: A 42-Year-Old with Fever and Hypotension. Okay, Cathy, here's today's question: A 42-year-old man has a history of splenectomy following trauma at the age of 20. He received the appropriate vaccinations immediately after his trauma but has not had any medical care for more than 10 years. He's currently homeless. He presents to the emergency department with a fever of 102.3°F, a blood pressure of 70/40 mmHg, a heart rate of a 130 beats/minute, a respiratory rate of 30 breaths/minute, and an oxygen saturation of 95% on room air.
CHARLIE: He subsequently develops multi-system organ failure, due to overwhelming sepsis, and dies despite appropriate medical management. First question I'd like to ask you: Is this expected or unexpected, and what are his major risk factors?
CATHY: In general, in a 42-year-old, you would not expect this outcome. But the major risk factor here is this patient's prior splenectomy. So, individuals who have had a splenectomy are at increased risk of death, due to sepsis, and the death rate is 58 times higher than that of the general population. Most infections occur within the first two years after splenectomy-- our patient's a bit farther out than that-- but the risk remains higher than the general population throughout life, even despite the vaccination. And, unfortunately, the mortality from sepsis in an individual who has had a splenectomy is about 50%.
CHARLIE: Which is much higher than most patients. So, the question's going to ask: "Which of the following organisms would be most likely to cause this patient's presentation?" Option A is E. coli; option B is Haemophilus influenzae; option C is Neisseria meningitidis; option D is Pseudomonas aeruginosa; and option E is Streptococcus pneumoniae.
CATHY: In asplenia, encapsulated bacteria cause the majority of the infections and that's because of the absence of natural filtration of microbes in the blood. Adults who are more likely to have antibodies to these organisms, are at lower risk than children. The most common organism causing sepsis in individuals who have had a splenectomy is Strep pneumoniae, so that would be option E. And this is responsible for 50-70% of cases of sepsis in asplenic patients. Now, other organisms to consider are those mentioned, but B and C, in particular, so H. influenzae and N. meningitidis do have a high incidence of sepsis in asplenic patients as well, and patients should be vaccinated against all of these organisms.
CHARLIE: So, a patient who is either about to undergo a splenectomy, or has had a splenectomy, should receive immunization against Strep pneumoniae, H. flu, and Neisseria meningitidis, right?
CATHY: Yes, that's correct.
CHARLIE: Okay. So, the answer to that question was Strep pneumoniae, but this is a two-part question. The question now asks: "What is the best initial antibiotic therapy for this patient when he first presented?" And the options are: A. ceftriaxone and vancomycin; B. ceftriaxone, ampicillin, and vancomycin; C. ceftriaxone, vancomycin, and amphotericin B; D. clindamycin, gentamicin, and vancomycin; or E. clindamycin and quinine.
CATHY: So, ceftriaxone-- which is a third-generation cephalosporin-- and vanc-- to cover the most common organisms like I mentioned. So, option A would be the best choice, and for these, you'd want to start at a higher dose. So, ceftriaxone, you'd give 2 g IV every 12 hours, and vancomycin would be 15 mg/kg every 12 hours. In addition to patients who do not have a spleen, there are patients who, for example, some sickle cell patients who have functional asplenia, and these patients should be treated the same way.
CHARLIE: What about the other choices, and why not include amphotericin B for fungal infections?
CATHY: Well, you don't need to add antifungal agents because of the most likely organisms that I mentioned before. Clindamycin is usually added to vancomycin, if you're concerned for toxic shock syndrome, which I'm not in this case, and there's no need to add antimalarial drugs in the absence of any relevant travel history. So, if the patient was just here in Baltimore, you don't need to do that. If he had just gotten back from a malaria-endemic region, then you might add that for a patient with this presentation.
CATHY: And you also don't need to add ampicillin, although that does provide extra coverage for H. flu.
CHARLIE: Okay. So, these were two quick, short questions, but the teaching points are: Asplenic patients are at the highest risk of sepsis from Strep pneumoniae, and their risk of death due to sepsis is higher in general than the general population. The best initial antibiotic therapy to cover a patient who is presenting with sepsis such as this would be to cover the most common causative agents, which include Strep pneumoniae, Haemophilus influenza, and Neisseria meningitidis, and an appropriate empiric regimen would be ceftriaxone and vancomycin.
CATHY: And to read more about this, you can check out Harrison's chapter on Infectious Diseases, but also look at Primary Immune Deficiencies, if you want to learn more about asplenia. ♪ (music) ♪